Dialectical behavior therapy

Dialectical behavior therapy (DBT) is a therapy designed to help people change patterns of behavior that are not helpful, such as self-harm, suicidal ideation, and substance abuse. This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviors to help avoid undesired reactions. DBT assumes that people are doing the best they can but are either lacking the skills or influenced by positive or negative reinforcement that interfere with their ability to function appropriately.

DBT is a modified form of cognitive-behavioral therapy (CBT), that was developed in late 1970s by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Although research on its effectiveness in treating other conditions has been extremely limited, DBT is now used in a variety of psychological treatments including treatment for traumatic brain injuries (TBI), eating disorders, and mood disorders. Scant research indicates that DBT might have some effect on patients who present varied symptoms and behaviors associated with spectrum mood disorders, including self-injury. Recent work also suggests its effectiveness with sexual abuse survivors and chemical dependency.

DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be generally effective in treating BPD. The first randomized clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.

Overview

Linehan observed "burn-out" in therapists after coping with "non-motivated" patients who repudiated cooperation in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments, and, therefore, required a climate of loving-kindness and somewhat unconditional acceptance (not Rogers’ positive humanist approach, but Hanh's metaphysically neutral one), in which to develop a successful therapeutic alliance. Her second insight involved the need for a commensurate commitment from patients, who needed to be willing to accept their dire level of emotional dysfunction.

DBT strives to have the patient view the therapist as an ally rather than an adversary in the treatment of psychological issues. Accordingly, the therapist aims to accept and validate the client’s feelings at any given time, while, nonetheless, informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives.

Linehan and others combined a commitment to the core conditions of acceptance and change through the principle of dialectics (in which thesis + antithesis → synthesis) and assembled an array of skills for emotional self-regulation drawn from Western psychological traditions, such as cognitive behavioral therapy and an interpersonal variant, "assertiveness training", and Eastern meditative traditions, such as Buddhist mindfulness meditation. One of her contributions was to alter the adversarial nature of the therapist-client relationship in favor of an alliance based on intersubjective tough love.

All DBT can be said to involve 4 components:

• Individual – The therapist and patient discuss issues that come up during the week (recorded on diary cards) and follow a treatment target hierarchy. Self-injurious and suicidal behaviors, or life-threatening behaviors, take first priority. Second in priority are behaviors which, while not directly harmful to self or others, interfere with the course of treatment. These behaviors are known as therapy-interfering behaviors. Third in priority are quality of life issues and working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
• Group – A group ordinarily meets once weekly for two to two-and-a-half hours and learns to use specific skills that are broken down into four skill modules: core mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.
• Therapist Consultation Team – A therapist consultation team includes all therapists providing DBT. The meeting occurs weekly and serves to support the therapist in providing the treatment.
• Phone Coaching – Phone coaching is designed to help generalize skills into the patient's daily life. Phone coaching is brief and limited to a focus on skills.

No one component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context.

Four modules

Mindfulness

Further information: Mindfulness (psychology)

Mindfulness is one of the core concepts behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one's emotions and senses fully, yet with perspective.

"What" skills

Observe

This is used to nonjudgmentally observe one’s environment within or outside oneself. It is helpful in understanding what is going on in any given situation.

DBT recommends developing a "teflon mind," the ability to let feelings and experiences pass without sticking in the mind.

Describe

This is used to express what one has observed with the observe skill. It is to be used without judgmental statements. This helps with letting others know what you have observed.

Participate

This is used to become fully focused on, and involved in, the activity that one is doing.

"How" skills

Nonjudgmentally

This is the action of describing the facts, and not thinking about what's "good" or "bad," "fair," or "unfair." These are judgments, not a factual description. Being nonjudgmental helps to get your point across in an effective manner without adding a judgment that someone else might disagree with.

One-mindfully

This is used to focus on one thing. One-mindfully is helpful in keeping your mind from straying into emotion mind by a lack of focus.

Effectively

This is simply doing what works. It is a very broad-ranged skill and can be applied to any other skill to aid in being successful with said skill.

Distress tolerance

Many current approaches to mental health treatment focus on changing distressing events and circumstances such as dealing with the death of a loved one, loss of a job, serious illness, terrorist attacks and other traumatic events. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.

Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Since this is a non-judgmental stance, this means that it is not one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.

Distract with ACCEPTS

This is a skill used to distract oneself temporarily from unpleasant emotions.

• Activities - Use positive activities that you enjoy.
• Contribute - Help out others or your community.
• Comparisons - Compare yourself either to people that are less fortunate or to how you used to be when you were in a worse state.
• Emotions (other) - cause yourself to feel something different by provoking your sense of humor or happiness with corresponding activities.
• Push away - Put your situation on the back-burner for a while. Put something else temporarily first in your mind.
• Thoughts (other) - Force your mind to think about something else.
• Sensations (other) – Do something that has an intense feeling other than what you are feeling, like a cold shower or a spicy candy.

Self-soothe

This is a skill in which one behaves in a comforting, nurturing, kind, and gentle way to oneself. You use it by doing something that is soothing to you. It is used in moments of distress or agitation. New York Jets wide receiver Brandon Marshall, who was diagnosed with BPD in 2011 and is a strong advocate for DBT, cited activities such as prayer and listening to jazz music as instrumental in his treatment.

IMPROVE the moment

This skill is used in moments of distress to help one relax.

• Imagery - Imagine relaxing scenes, things going well, or other things that please you.
• Meaning - Find some purpose or meaning in what you are feeling.
• Prayer - Either pray to whomever you worship, or, if not religious, chant a personal mantra.
• Relaxation - Relax your muscles, breathe deeply; use with self-soothing.
• One thing in the moment - Focus your entire attention on what you are doing right now. Keep yourself in the present.
• Vacation (brief) - Take a break from it all for a short period of time.
• Encouragement - Cheerlead yourself. Tell yourself you can make it through this and cope as it will assist your resilience and reduce your vulnerability.

Pros and cons

Think about the positive and negative things about not tolerating distress.

Radical acceptance

Let go of fighting reality. Accept your situation for what it is.

Turning the mind

Turn your mind toward an acceptance stance. It should be used with radical acceptance.

Willingness vs. willfulness

Be willing and open to do what is effective. Let go of a willful stance which goes against acceptance. Keep your eye on the goal in front of you.

Emotion regulation

Further information: Emotional self-regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:

• Identify and label emotions
• Identify obstacles to changing emotions
• Reduce vulnerability to emotion mind
• Increase positive emotional events
• Increase mindfulness to current emotions
• Take opposite action
• Apply distress tolerance techniques

Story of emotion

This skill is used to understand what kind of emotion one is feeling.

1. Prompting event
2. Interpretation of the event
3. Body sensations
4. Body language
5. Action urge
6. Action
7. Emotion name, based on previous items on list

PLEASE

This skill concerns ineffective health habits can make one more vulnerable to emotion mind. This skill is used to maintain a healthy body, so one is more likely to have healthy emotions.

PhysicaL illness (treat) - If you are sick or injured, get proper treatment for it.

Eating (balanced) - Make sure you eat a proper healthy diet, and eat in moderation.

Avoid mood-altering drugs - Do not take non-prescribed medication or illegal drugs. They are very harmful to your body, and can make your mood unpredictable.

Sleep (balanced) - Do not sleep too much or too little. Eight hours of sleep is recommended per night for the average adult.

Exercise - Make sure you get an effective amount of exercise, as this will both improve body image and release endorphins, making you happier.

Build mastery

Try to do one thing a day to help build competence and control.

Opposite action

This skill is used when you have an unjustified emotion, one that doesn’t belong in the situation at hand. You use it by doing the opposite of your urges in the moment. It is a tool to bring you out of an unwanted or unjustified emotion by replacing it with the emotion that is opposite.

Problem solving

This is used to solve a problem when your emotion is justified. It is used in combination with other skills.

Letting go of emotional suffering

Observe and experience your emotion, accept it, then let it go.

Interpersonal effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.

Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing their own situation.

The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.

DEARMAN - getting something

This acronym is used to aid one in getting what he or she wants when asking.

• Describe your situation.
• Express why this is an issue and how you feel about it.
• Assert yourself by asking clearly for what you want.
• Reinforce your position by offering a positive consequence if you were to get what you want.
• Mindful of the situation by focusing on what you want and ignore distractions.
• Appear Confident even if you don’t feel confident.
• Negotiate with a hesitant person and come to a comfortable compromise on your request.

GIVE - giving something

This skill set aids one with maintaining their relationships, whether they are with friends, coworkers, family, romantic partners, etc. It is to be used in conversations.

• Gentle: Use appropriate language, no verbal or physical attacks, no put downs, avoid sarcasm unless you are sure the person is alright with it, and be courteous and non-judgmental.
• Interested: When the person you are speaking to is talking about something, act interested in what they are saying. Maintain eye contact, ask questions, etc. Do not use your cell phone while having a conversation with another person!
• Validate: Show that you understand a person’s situation and sympathize with them. Validation can be shown through words, body language and/or facial expressions.
• Easy Manner: Be calm and comfortable during conversation, use humor, smile.

FAST - keeping self-respect

This is a skill to aid one in maintaining their self-respect. It is to be used in combination with the other interpersonal effectiveness skills.

• Fair: Be fair to both yourself and the other person.
• Apologies (few): Don’t apologize more than once for what you have done ineffectively, or apologize for something which was not ineffective.
• Stick to Your Values: Stay true to what you believe in and stand by it. Don’t allow others to get you to do things against your values.
• Truthful: Don’t lie. Lying can only pile up and damage relationships and your self-respect.

This list does not include the "problem solving" module, the purpose of which is to practice being one's own therapist.

Tools

Diary cards

Specially formatted cards for tracking therapy interfering behaviors that distract or hinder a patient's progress. Diary cards can be filled out daily, 2-3 times a day, or once per week.

Chain analysis

Chain analysis is a form of functional analysis of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular applied behavior analysis concept of chaining. A growing body of research supports the use of behavior chain analysis with multiple populations.

Milieu

The milieu, or the culture of the group involved, plays a key role in the effectiveness of DBT.

See also

• Acceptance and commitment therapy
• Rational emotive behavior therapy
• Nonviolent communication
• Emotional dysregulation
• Mentalization-based treatment
• Social skill
• Behavioral psychotherapy
• Cognitive emotional behavioral therapy

Sources

• Linehan,M.M., Comtois K.A., Murray A.M., Brown M.Z., Gallop R.J., Heard H.L., Korslund K.E., Tutek D.A., Reynolds S.K., Lindenboim N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry, 63(7), 757-66.
• Linehan,M.M., Heard,H.L. (1993) "Impact of treatment accessibility on clinical course of parasuicidal patients": Reply. Archives of General-Psychiatry, 50(2): 157-158.
• Linehan,M.M., Tutek,D.A., Heard,H.L., Armstrong,H.E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151, 1771-1776.
• Linehan,M.M., Schmidt,H., Dimeff,L.A., Craft,J.C., Kanter,J., Comtois,K.A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addiction, 8(4), 279-292.
• Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Welch, S.S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67(1), 13-26.
• Koons, C.R., Robins, C.J., Tweed, J.L., Lynch, T.R., Gonzalez, A.M., Morse, J.Q., Bishop, G.K., Butterfield, M.I., Bastian, L.A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32(2), 371-390.
• van den Bosch, L.M.C., Verheul, R., Schippers, G.M., van den Brink, W. (2002). Dialectical Behavior Therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27(6), 911-923.
• Verheul, R., van den Bosch, L.M.C., Koeter, M.W.J., de Ridder, M.A.J., Stijnen, T., van den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. British Journal of Psychiatry, 182, 135-140.
• Linehan et al. (2006) NIMH 3 Two-Year Randomized Control Trial and Follow up of DBT

Further reading

• The Miracle of Mindfulness by Thich Nhat Hanh. ISBN 0-8070-1239-4.
• Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan. 1993. ISBN 0-89862-034-1.
• Cognitive Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan. 1993. ISBN 0-89862-183-6.
• Fatal Flaws: Navigating Destructive Relationships with People with Disorders of Personality and Character by Stuart C. Yudovsky. ISBN 1-58562-214-1.
• The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation by Alan E. Fruzzetti. ISBN 1-57224-450-X.
• Dialectical Behavior Therapy with Suicidal Adolescents by Alec L. Miller, Jill H. Rathus, and Marsha M. Linehan. Foreword by Charles R. Swenson. ISBN 978-1-59385-383-9.
• Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance (New Harbinger Self-Help Workbook) by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley. ISBN 978-1-57224-513-6.
• Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control (New Harbinger Self-Help Workbook) by Scott E. Spradlin. ISBN 978-1-57224-309-5.
• Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression & Anxiety by Thomas Marra. ISBN 978-1-57224-363-7.

External links

• Priory's An Overview of Dialectical Behaviour Therapy
• Overview of Borderline Personality Disorder and DBT treatment
• Marsha Linehan's description of DBT